S1820APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS
y
OWNER'S NAME PHONE.
ARCHITECT/ENGINEER: IC NO:
I
CONTACT %../sG°[' PHONEs'�'�1✓
! LICENSED CONTRACTOR'S DECLARATION
QTY.
1 hereby alfirm that 1 am licensed under provisions of Chapter 9 (commencing
QC) Z with Section 70(X)) of Division 3 of the Business and Professions Code, and my licensers
F» WW in full force and ,.. � �.
QU U� License Class - �Lic. #
F z W Date " / " ` Contractor J 'r C
Con Q V) ARCHITECT'S DECLARATION
Z O V) Z I understand my plans shall be used as public records
O'z4QI
1-. ,�„ F: W Licensed Professional
a aG OWNER -BUILDER DECLARATION
G. W W QII I hereby affirm that I am exempt fiom the C'ontractor's License Law for the
X 0 0, U following reason. (Section 703 1.5, Business and Professions Code: Any city or county
W 3 W cn which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
WW that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
WQ 0 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
0. 0. C4 that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Xl * Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
W .-. V) not more than five hundred dollars ($500)
Q� ❑ I, as owner of the property, or my employees with wages as their sole compensation,
F. will do the work, and the structure is not intended or offered for sale ( Sec. 7041, Business
W�i and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
jsale. If, however, the budding or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and QTY.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
! License Law.
❑ 1 am exempt under Sec. . B & P C for this reason
Owner Date
I WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations.
'I ❑ I have and will maintain a Certificate of Consent to self insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker; Coi pensation,In,ur rice carrier and Pohcy number are _ w
Carrier: r - _ �' �L Policy No.. �t % Y �w I /✓G'
CERTIFICATE OF EX MPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it [he permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this penrnt is issued, 1 shall
not employ any person in any manner so as to become subject to the Workers' Compcn-
,Z sation Laws of California. Dale
Applicant
z,
i..i NOTICE TO APPLICANT If, after making this Certificate of Exemption, -you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
W> forthwith comply with such provisions of this permit shall be deemed revoked.
a Q!
CONSTRUCTION LENDING AGENCY
U O I hereby affirm that there is a construction lending agency for the performance of
w i --i the work for which this permit is issued (Sec 3097, Civ. C 1
O ULender's Name
Lender's Address
a 1 certify [hat I have read this application and state that the above information is
V) correct. I agree to comply with all city and county ordinances and state laws relating to QTY.
U Zbuilding construction, and hereby authorize representalives of this city to enter upon the
i --I above-mentioned property for inspection purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against
lmahihties, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
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s( )I l2(I RI({f 1 \11O\s
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant afore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
1 Code, Section 25532(x)''
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
jemit hazardous air contaminants as defined by the Bay Area Air Quality Management
District"
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chaplet 6 95 of the Call -
forma Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
budding docs not currently have a tenant, that it is my responsibility to notify the occupant
of the Nuirements which must be met prior to issuance of a Certificate A Occupancy.
/ ,.rn it /1 f44 _ ` /� P f `11
Owner or authorized agent %
LIC NO:
'r y
Consultant Fees Paid be Applicant (initial)
rr.St t NU 182 0
SANITARY NO. APPLICATION SUBMITTAL DATE
N/C C'ONTROL #
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
- - CR' ❑ ❑ Com'
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
❑ ADDITION ❑ PLUMBING RE -PIPE
❑ MULTI -UNIT El STRUCTURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHF,R _
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
201-1000 AMPS
OVER IWO AMPS
SIGNS ELECTRICAL_
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEN10LITION
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
!
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT FLOOR AREA
5/SQ FT.
TOTAL:
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VEN R(EA)
VALUATION
C
J J
BACK FLOW PROT T. V 'E/'�
DRAINS - FLOOR, ROOF, ARE N
S ORIES
OCC GROUP
TYPE CONSTRUCTION
APN
'01—
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA SYSTEM -OVER 4 (EA)
Il`
GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECKFEE
SEWER - SANITARY - STORM EA. 200 FT. I
ENERGY FEE
WATER HEATER W/VENT/ELEC'TR
GRADING FEE
WATER SYSTEM/TREATING
SOILS FEE
WATER SERVICE
PAID
#
,.
NEW RESIDENTIAL PLMB SQ FT.
-
-�--_Date -._ _---Receipt
MAL'
"TOTAL:�
,
BUILDING FEE ;
MECHANICAL PERMITFE
PERMITISSUANCEI
[SbtLiiF FEE
ELECTRIC FEE
AI TER OR ADD TO MECH.
PLL
SING FL$ , "r
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,(1(X) CFM)
CONSTRUCTION TAX
1
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,(X)0 BTU) 1/
2•-Zt
HEATING UNIT (OVER 100,000 BTU)
PAID
Date Receipt It
VENTILNHON FAN (SINGLE RESID)
BOILER - COMP (3HP OR 1(X),000 BTU)
TOTAL:
BOILER- COMP (OVER 10110)0 BTU)
AIR CONDITIONER
li
ISSUANCE DATE
ISSUED BY, TQ tf '41 l �J k' V C L
NEW RESIDENTIAL MECH SQ. FT.
i
TOTAL�i/ �, 9 Q
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OFFICE
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
All
..�� �n.,151;g.
Gas
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FINAL INSPECTIONS DATE I INSP.
re De17t .
ELECTRICAL DATE J INSP.
Underfloor S.M.
ase
clues 4 c:oMI), Alr I